阿曲库铵诱导的神经肌肉阻滞恢复过程中的双爆发刺激监测：与四个成串刺激的比较

Kirkegaard-Nielsen H, Helbo-Hansen H S, Severinsen I K, Lindholm P, Bülow K

Department of Anaesthesia and Intensive Care, Odense University Hospital, Denmark.

Int J Clin Monit Comput. 1996 Nov;13(4):209-15. doi: 10.1023/a:1016929721934.

BACKGROUND

Double burst stimulation (DBS) was originally introduced for improved manual detection of residual neuromuscular blockade. Previous studies demonstrated a high correlation between mechanomyographical responses to DBS and train-of-four (TOF) stimulation during recovery from neuromuscular blockade. However, repeatability and bias analyses that are recommended when new monitoring devices are introduced into clinical practice [11] have not yet been performed.

OBJECT

The object of the present study was to evaluate if DBS3,350/50 (3 stimuli at 50 Hz followed 0.750 sec later by 3 stimulations at 50 Hz) and TOF measurements are in so close agreement that they can be used interchangeably during spontaneous recovery from atracurium blockade.

METHODS

The study comprised 20 women undergoing gynaecological laparotomy and anaesthetised with fentanyl, thiopentone, halothane, and nitrous oxide. The neuromuscular blockade was induced and maintained with atracurium. The ulnar nerve was stimulated using DBS or TOF stimulation. Neuromuscular transmission was monitored mechanomyographically. Alternating sequences of 4 DBS and 6 TOF stimulations were applied during the phase of spontaneous recovery. Repeatability, bias (accuracy) and limits of agreement were calculated as proposed by Bland and Altman [11].

RESULTS

The repeatability coefficients before any neuromuscular blocking agent was given were 3.4 and 7.7% for T1 and D1, respectively (P < 0.05), and 3.8 and 3.5% for TOF ratio and DBS ratio, respectively (P > 0.05). The mean difference between duplicated DBS and TOF measurements during recovery (repeatability) differed from zero due to the ongoing recovery process. It was therefore not possible to calculate the repeatability coefficients. The DBS ratio bias decreased from 6.69 to 3.51% (P < 0.05) during recovery. The limits of agreement between the DBS and TOF ratios increased from -2.07 to 15.45%, to -11.93 to 18.95% during recovery, while the limits of agreement between the DBS and TOF twitch heights increased from -5.02 to 10.68%, to -21.02 to 25.26%.

CONCLUSION

The limits of agreement between DBS and TOF responses were so wide that DBS and TOF can not be used interchangeably.

背景

双爆发刺激（DBS）最初用于改善残余神经肌肉阻滞的人工检测。先前的研究表明，在神经肌肉阻滞恢复过程中，对DBS的肌机械图反应与四个成串刺激（TOF）之间存在高度相关性。然而，当新的监测设备引入临床实践时所推荐的重复性和偏倚分析[11]尚未进行。

目的

本研究的目的是评估DBS3,350/50（50Hz下3次刺激，0.750秒后接着50Hz下3次刺激）与TOF测量是否非常一致，以至于在阿曲库铵阻滞的自发恢复过程中可以互换使用。

方法

该研究包括20名接受妇科剖腹手术并使用芬太尼、硫喷妥钠、氟烷和氧化亚氮麻醉的女性。使用阿曲库铵诱导并维持神经肌肉阻滞。使用DBS或TOF刺激尺神经。通过肌机械图监测神经肌肉传递。在自发恢复阶段应用4次DBS和6次TOF刺激的交替序列。按照Bland和Altman[11]的建议计算重复性、偏倚（准确性）和一致性界限。

结果

在给予任何神经肌肉阻滞剂之前，T1和D1的重复性系数分别为3.4%和7.7%（P<0.05），TOF比值和DBS比值的重复性系数分别为3.8%和3.5%（P>0.05）。由于恢复过程持续进行，恢复期间重复的DBS和TOF测量之间的平均差异与零不同。因此无法计算重复性系数。恢复期间DBS比值偏倚从6.69%降至3.51%（P<0.05）。DBS与TOF比值之间的一致性界限从-2.07%至至15.45%增加到恢复期间的-11.93%至18.95%，而DBS与TOF颤搐高度之间的一致性界限从-5.02%至10.68%增加到-21.02%至至25.26%。